Course Name: SAMPLE Student Consent Agreement

Consent to the Collection, Use, Disclosure and Storage of

Personal Information When Using Textbook Name

in VIU Course Name

This form is used to obtain your informed consent to the collection, use, disclosure and storage of your personal information when using 3rd party web-based technology (web-based assignments, quizzes and lab activities in Textbook Name) in this course for required learning.

*Please carefully read, fill out and sign the form below. If you have any questions or concerns about the form or the protection of your privacy, please consult the instructor.

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Student Name: ______Date: ______

Course: ______Instructor: ______

Description of the Uses and theTechnology to be Used

Project or Assignment: Completion and submission of Textbook Name Activities (1. Weekly quizzes, 2. Resource Labs and 3. Engaging in practice questions)

Technology to be Used: Textbook Name web environment called X

As part of the course requirements for VIU Course Name, you will be asked to participate and complete activities for course assignments and assessments throughout the semester. The Textbook Name for this course has a fully online web environment that you need to create an account in, log in to each week, use the resources and materials as well as complete labs and quiz activities. The online textbook environment is password protected, but requires you to create a log in and password.

Reason for using Textbook Name

As part of the problem solving and evaluation requirements for your course, each student is asked to complete lab assignments to develop problem-solving skills, reinforce class and textbook learning, and demonstrate an understanding of the principles and procedures of the core concepts of this course from a user perspective. Assignments and quizzesin this course will be marked using online textbook environment’stechnology. Student workand marks stored on the systemwill be password protected using a password chosen by the student. The instructor is also able to view student activity and marks on the Textbook Name site.

Advantages of using Textbook Name Environment

  • Access to a searchable, online, electronic version of the entire course textbook.
  • Access to electronic resources enhancing learning, tips for completing assignments, and context-relevant links to text materials.
  • Instant feedback on your work through immediate marking.
  • Ability to complete additional practice questions if desired

Privacy Information (all sample info – add Q + A components to your textbook here)

The following are the publisher's responses to questions about privacy. Note the link to the publisher's online privacy statement. Questions below are in italics, with publisher's answer bulleted below each question.

  • When a student registers with Textbook Name exactly what information is collected, and how is that information used? Is all the information asked for on the registration form required, or can student opt to complete only part of the form? Do you collect the student email address, and if so, is that required?
  • When students register for Textbook Namethe only required fields are:
  • First and Last Name
  • Email Address (does not have to be the school’s email address –can be any email address, and does not need to be a valid address)
  • Password (the student creates this on their own)
  • Student Number – this is optional, students are not required to complete
  • This information is used to connect this student to their Textbook NameAccount and for Textbook NameTech Support Team to help them with any Textbook Name concerns. The above information is required for the instructor’s roster and gradebook. The email address is used by students to login to Textbook Name. This information is not shared or used for any other purpose.See Identifiable Privacy Risks below.
  • Our online Privacy Statement is located at
  • How long does student information remain on your servers after the Textbook Namecourse is completed by the student?
  • The information is sorted for as long as the student is registered in an active Textbook Namecourse. As many schools require student gradebook info to be kept available after a class is over in case it is needed by the student or the school. Textbook Namewill maintain the gradebook data for a period of at least three years.
  • Does Textbook Namegive, sell, or in any other way make student information available to any third parties?
  • No, absolutely not.

Identifiable Privacy Risks(sample text from a publisher below, insert your own)

According to the publisher's privacy statement, identifiable student information stored on Textbook Nameservers includes name, email, password, student number (optional). This information:

  • is located on United States servers, located outside of Canada, and therefore the company is not required to comply with Canadian or British Columbia privacy legislation.
  • May be shared with:
  • third parties "where necessary in connection with services provided by appropriate intermediaries, who will be required to comply with the confidentiality provisions of this policy," and
  • in situations where you have given your consent, and
  • when the publisher is "required by law or otherwise needed in connection with legal proceedings."This means that your student information is on US servers, subject to search and seizure for any reasons the law wishes to have for acquisition.
  • will contain your marks which are will be kept "for a period of at least 3 years."
  • If you provide the publisher with your postal address (this information is not required) you may receive mailings from the publisher, who may also share your address with other companies at its discretion unless you advise that you do not wish this. VIU recommends that you do NOT share your postal address unnecessarily.

You may elect to use an instructor-assigned alias, email address and password if you have concerns about the privacy risks of personally identifiable information.

Fill out the agreement below, clearly marking your name and registration option choice. Sign and date the form, then keep pages 1 and 2 of this document for your own reference, and give the completed and signed form on this page to your instructor.

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Student Consent Statementfor Course Name

I, ______, agree to the collection, use, disclosure and storage of my personal information inside or outside of Canada while using the technology described on the previous page for the purposes of engaging in this class. I am aware of and understand the identifiable privacy risks as described above and will endeavour to minimize exposure of my and other people’s personal information by collecting, using and disclosing only that information that is necessary to complete the course in the manner prescribed by the instructor.

I understand that I may use an instructor-assigned pseudonym to remain anonymous online for the purposes of this class to minimize exposure of my or other people’s personal information to 3rd parties that are not part of this class or project or who are otherwise not entitled to this information.

Registration options (check one)

____ I will use my own name and email address to register with Textbook Name

____ I wish to use a pseudonym to remain anonymous online for the purposes of this class (see note below).

This consent is valid until (course end date) unless revoked by me in writing and delivered to the instructor.

Student Signature: ______Date: ______

Note: Students who wish to use a pseudonym will be assigned a fake name, email address and password by the instructor. If a student loses or forgets his/her password, he/she would retrieve it by emailing the instructor.

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Student Consent Agreement for Course Name